44 CEDAR ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Leeibly
Vame tHuciness/OrganiratioNlndiwchwl): PQ(Z 0 Q 4 qi L.\j 4
Address: W C6-DA-k _5- E- 1r
City1SlarciZip:$,,q��'1 O/A' 0/990 Phoned: !ZW-973- 09ld
jAre u an employer?Chec the appropriate lox: 'type of project(required):
t.cant a employer with OL 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. : 7• ❑ Remodeling
ship and have no employees 'these sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exerciwxl thew
10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑ P robing repairs or additions
myself. (No workers comp. c. 152,§1(4),and we have no 12.®Reof repairs
insurance required.j t employees.(N'o workers' 13.❑
comp. inswrance required.]
Other-
-Any applicant thin chucks has el most also till ow the seclion below sltowiag nh4ir workers'euntptmatiot policy inf lnevaiwl,
t Ilo mwnen who submit this affidavit indicating they am doing all work and[it=hire outside cono:cion m of submit a new amdavit indicting Mich.
�Cuntnaex,that check this box must attached an additional Alton showing the 112104 of the subbconratn4ts and their wurkers'comp.policy information.
rum mn carployer that is providing nvorkers'compenradon lnsurancefor toy employees. Below is the policy and job site
information.
Insurance Company Name:. e0JP-23.DF-3
-oltcy#or Self-ins. Lic. 5 0453 - . .__._ Expiration Date:
Job Site Adekcss:�l l�G'�� � CityrSlatd2ip:S
A4,_t,M
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure w secure coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penalties of a
fins up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Ol7ice of
lu%csngations ol'the DIA for insurance coverage verification. -
I do hereby ce 'y under the pains misfit penalties of perjury that the infurtnullon provided above is true and correct.
Sietttitr•'. S-� I.- 04_,C..� Date• rZ
11_a __6?3 9 _ 3 9 4 3
OJJlcial me only. Do not write in this area,to be completed by city or town aJjicfaz
City or'fawn: _ PermitiLicense J#
---
Issuing Authority(circle one):
1. Iloard ur health 2. Building Department 3.Citylrovtu Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
contaet Person: -- I'honc #:
r
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire.
express or implied,oral or written"
:Vt employer is defined as"an individual,partnership,association.corporation or other legal entity,or any two or more
of the foregoing engaged in a Joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of ao individual,purnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartment$and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
A1GL chapter 152. §25C(6)also states that"every state or legal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
appUeaul who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth a"any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and if
necessary,supply sub-contractor(s)name(s),addresses)and phone number(s)along with their cerrificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. if an LLC or LLP does have
employees,a Policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appro riate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom.
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple penmitllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address'the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
l'hc Ottiec of lnvestigations would like to thank you in advance for your cooperation and should you have any questions,
Please du not hesitate to give us a call.
The Dcparment's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
O®ee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.masa.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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TV:976-7454M •E.\x:97L7469$*
Construction Debris Disposat Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris,and the provisions of M. GL c 40. S 54;
Building Permit 0 __ _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I It.3 150A.
t
The debris will be transported by:
(siamd of hauler)
The debris will be disposed of in :
A/oR�LN-s 1 D E . C14,2 r nV 4
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y "y BOARD OF BUILDING REGULATIONS ==3
I License: CONSTRUCTION SUPERVISOR .'
Number:.CS 053654`,
Birthdate::04/18/1954
Expires: 09J812007 Tr.no: 4607.0
0.4 Restricted: 00
ARTHUR S BETTENCOURT -
20 ESQUIRE DR t��
j I PEABODY. MA 01960 `. Commissioner ✓
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✓fie �noai»naruaea�d a�✓l�aaaac%uer•C1d I'
- $oard of Banding Regulations and Standards
HOMEIMPROVEMENTCONTRASTOR- ''...
Registration .135731
Expiration: 5%2/2008 Tr# 127617
Type: DBA '
i
A.S.BETTENCOURT
ARTHUR BETTENCOURT
20 ESQUIRE DR. "'_. —`
PEABODY,MA 01960. t�dmiplstrntor
EI'T'StOF _ _
PUBLIC PROPERTY
DEPAR'I11dENT
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/Aral 130 WwsWlu=*b'MEEr•SMAW XMSA01LS1:19901970
14L•972-745-9S93•FAX:M7404M
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING-
1.0 SITE INFORMATION
Location Name: Building:
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- - - - -
Property Address:--r-/-
Property Is located in a.Conservation Area Y/N Hlstaric DWkkt Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land 1� a
Name: C o S l Z v 14
Address: l f c
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sQ Renovated
construction or renovation
of existing building N New
86ef Description of Proposed Work:
C�1=�J19f'
-- Mail Permit to: S, FCME ICOUK i a-o
--
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What is the current use of the Building? )
Material of Building? - &_ If dwelling.how many units?
Win @ro Building Conform to Law? _Yl� Asbestos?
grchited's Name S T�� ( g —��
Address and Phone C .
Mechanic's Name
Address and Phone
Construction Supervisors License#C HIC Registration 0
Estimated Cost Ojed >U n Pem*Fee CalcuMM
Permit Fee 9 Estlmated Cost X i?IS1txIo Residential
-- _ - Estimated Cost $11/111000 Commercia'-------__..
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury -
Ll'
Date - � -
of
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